Provider Demographics
NPI:1053508945
Name:BAILEY, DERRICK A (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:A
Last Name:BAILEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900SEPORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5554
Mailing Address - Country:US
Mailing Address - Phone:772-335-2614
Mailing Address - Fax:
Practice Address - Street 1:240 EAST ST
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-2935
Practice Address - Country:US
Practice Address - Phone:860-747-4541
Practice Address - Fax:860-793-1218
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT23594207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine